This morning Shankar drove us all in to the hospital. First we stopped at Model hospital to see a patient. There has been earthquake damage at this hospital, as you can see by the cracks in the balcony. The upper floor had to be evacuated, and many patients were taken to Kirtipur.
The patient that we saw is 28 and had suffered a burn on his scalp many years ago. Over time he has developed a Marjolin's tumor or ulcer, which is an aggressive form of squamous cell cancer that forms in scars. It is now invading his dura and sinus, and although is has shrunk in size with some treatments, there will be no cure. His CT scans are quite impressive and unfortunately his outlook is not good. He is already having weakness on one side and other symptoms.
Once we made it to Kirtipur Hospital, Shankar gave us a real tour. His potential for expansion and dreams are very great, and his enthusiasm is limitless. He is determined that this facility will take care of all comers and provide care to the poor. He is currently struggling to get his colleagues to accept this vision, as many drivers of career choices involve income. But something tells me he will prevail.
Dr. McGee operating with local maxillofacial surgeon. This young man of 16 had an enlarging AV malformation on the left side of his tongue and was faced with a possible hemiglossectomy. A more conservative plan was utilized, to sclerose the mass by injecting the blood vessels with a sclerosing agent.. All went well.
The PACU is packed. They keep all patients overnight here after surgery, and some patients have come before surgery to be hydrated, have dressing changes, and be ready for surgical care. All ages, genders, and wound types gather here. Cynthia is helping where she can, but the biggest obstacle is having the staff develop and follow protocols for the care they give.
There is one patient in the PACU who is over 70% burned. Even in the best of centers, her care would be prolonged, painful, and expensive. Here in this small unit, she is being treated as best as possible. Our team had suggested that maybe this was beyond our reach, but Shankar will not give up on her. Tomorrow she comes to the OR for clean-up and re-evaluation, but she will be given every chance to show her potential to survive before the efforts are turned to comfort only.
Patient family waiting in beautifully colored local dress.
Cynthia supervising administration of blood. As the patient had no armband, checking the blood to be given was a nightmare for us who check blood in the West. The nurse brought the blood over and began to hang it, and I had to stop her and make her check with me that it was the right blood type, unit, and patient. The son had to identify the patient, and as Nepal uses a different calendar year, I was sure the blood was expired. But it was truly for June, not February (Nepali calendar, http://calendopedia.com/nepalese.htm), and the patient got his needed care.
On closer look, you can see the clever way the blood is being warmed. The bottle hung from the IV pole is hot water and the tubing passes through it. Otherwise blood is chilled and can cause a patient to shiver. This patient was already a few degrees below normal temperature, so we had to do something quick. Fluid resuscitation is quite behind in all of these patients, which we hope to remedy.
Lunch break. Rashmi is one of the scrub techs, and she began sharing her lunch with everyone. The generosity and comradery are amazing here. Also seated are the maxillofacial surgeon (have got to get her name today!), and Richard, our team circulating nurse. Richard is struggling with issues of sterile processing and set-up of sterile equipment. He is learning the obstacles they face here, but also there needs to be more attention to sterility. He is mulling over how best to help and this chapter will unfold as we go.
Older gentleman who was tending his animals and got hit by large rocks and rubble. He has a large gap in his tibia, which the frame will help bring together, but meanwhile the area had to be covered to keep out infection and allow healing. Here the pedicle flap made from the soleus muscle is fanned out to cover the shin area.
Mohan manually cross-hatching some skin to span over the new flap.
The patient that we saw is 28 and had suffered a burn on his scalp many years ago. Over time he has developed a Marjolin's tumor or ulcer, which is an aggressive form of squamous cell cancer that forms in scars. It is now invading his dura and sinus, and although is has shrunk in size with some treatments, there will be no cure. His CT scans are quite impressive and unfortunately his outlook is not good. He is already having weakness on one side and other symptoms.
Once we made it to Kirtipur Hospital, Shankar gave us a real tour. His potential for expansion and dreams are very great, and his enthusiasm is limitless. He is determined that this facility will take care of all comers and provide care to the poor. He is currently struggling to get his colleagues to accept this vision, as many drivers of career choices involve income. But something tells me he will prevail.
He is adding a new OR suite for all kinds of surgery, a PACU, ICU, and other areas. In the photo above, he is showing us a ward that they populated with beds in case they needed them for earthquake injury treatment, but they were able to take care of everyone who came upstairs. He said they sent no one away and treated the hundreds of patients who came his way.
One of Shankar's innovations was the cafeteria. He makes sure that each patient and one family member get meals. Anyone who buys meals is putting money into a hospital fund. For example, there are 4 people employed by the cafeteria who clean the hospital floors each day. Shankar hopes to deliver food to local businesses and schools for a price, enlarging the cafeteria funds. As the money grows, they can decide which project to fund next.
One of Shankar's innovations was the cafeteria. He makes sure that each patient and one family member get meals. Anyone who buys meals is putting money into a hospital fund. For example, there are 4 people employed by the cafeteria who clean the hospital floors each day. Shankar hopes to deliver food to local businesses and schools for a price, enlarging the cafeteria funds. As the money grows, they can decide which project to fund next.
Dr. McGee operating with local maxillofacial surgeon. This young man of 16 had an enlarging AV malformation on the left side of his tongue and was faced with a possible hemiglossectomy. A more conservative plan was utilized, to sclerose the mass by injecting the blood vessels with a sclerosing agent.. All went well.
The PACU is packed. They keep all patients overnight here after surgery, and some patients have come before surgery to be hydrated, have dressing changes, and be ready for surgical care. All ages, genders, and wound types gather here. Cynthia is helping where she can, but the biggest obstacle is having the staff develop and follow protocols for the care they give.
There is one patient in the PACU who is over 70% burned. Even in the best of centers, her care would be prolonged, painful, and expensive. Here in this small unit, she is being treated as best as possible. Our team had suggested that maybe this was beyond our reach, but Shankar will not give up on her. Tomorrow she comes to the OR for clean-up and re-evaluation, but she will be given every chance to show her potential to survive before the efforts are turned to comfort only.
Patient family waiting in beautifully colored local dress.
Cynthia supervising administration of blood. As the patient had no armband, checking the blood to be given was a nightmare for us who check blood in the West. The nurse brought the blood over and began to hang it, and I had to stop her and make her check with me that it was the right blood type, unit, and patient. The son had to identify the patient, and as Nepal uses a different calendar year, I was sure the blood was expired. But it was truly for June, not February (Nepali calendar, http://calendopedia.com/nepalese.htm), and the patient got his needed care.
On closer look, you can see the clever way the blood is being warmed. The bottle hung from the IV pole is hot water and the tubing passes through it. Otherwise blood is chilled and can cause a patient to shiver. This patient was already a few degrees below normal temperature, so we had to do something quick. Fluid resuscitation is quite behind in all of these patients, which we hope to remedy.
Lunch break. Rashmi is one of the scrub techs, and she began sharing her lunch with everyone. The generosity and comradery are amazing here. Also seated are the maxillofacial surgeon (have got to get her name today!), and Richard, our team circulating nurse. Richard is struggling with issues of sterile processing and set-up of sterile equipment. He is learning the obstacles they face here, but also there needs to be more attention to sterility. He is mulling over how best to help and this chapter will unfold as we go.
Older gentleman who was tending his animals and got hit by large rocks and rubble. He has a large gap in his tibia, which the frame will help bring together, but meanwhile the area had to be covered to keep out infection and allow healing. Here the pedicle flap made from the soleus muscle is fanned out to cover the shin area.
Mohan manually cross-hatching some skin to span over the new flap.
Voila - finished product! And a chance to heal and survive.
